Photo: Dominika Roseclay/Pexels
With an explosion in COVID-19 cases in India, patients find themselves more confused and helpless than ever. Private practitioners are prescribing up to a dozen medicines for even mild COVID-19 while their government counterparts tend to limit their prescription to five, even in severe COVID-19 cases.
To further perplex the Indian patient, scores of WhatsApp messages advise the use of kaadha1, a bland diet, herbal concoctions, even significant drugs like hydroxychloroquine.
The striking disparity between COVID-19 advice and treatment is attributable primarily to India’s sluggish treatment guidelines, which create a vacuum that doctors seek to fill by themselves. Though the Union health ministry website lists a basic treatment protocol, it lacks crucial information regarding lab investigations of choice, warnings for off-label use of blood thinners and advisories against the use of antibiotics and immunosuppressants (baricitinib, tofacitinib, etc.).
Further, the health ministry has not issued any statements ensuring strict adherence to the treatment guidelines. So doctors are prescribing even drugs that have limited, inconclusive or negative evidence. For example, antibiotics like azithromycin and doxycycline are still commonly advised for COVID-19 despite large clinical trials having found no evidence for their use, and despite the WHO’s persistent messaging.
These medicines are supposed to be useful in patients with specific clinical features and a high risk of developing a superimposed bacterial infection over the standard COVID-19 pneumonia. But many practitioners have been prescribing them as a blanket therapy for all COVID-19 patients.
The mass prescription of these highly useful antibiotics increases the risk of them turning useless, thanks to antibiotic resistance, in the coming years.
Even drugs that have proven benefits in managing COVID-19 are often prescribed at inappropriate clinical stages of the disease. For example, dexamethasone and methylprednisolone – steroids famous for having demonstrated a sharp mortality – benefit only patients with moderate to severe COVID-19. But many doctors have advised their use to patients with mild COVID-19.
This is particularly problematic since steroids can be rather harmful to the mildly ill, predisposing them to infections and dysregulated blood sugar. Steroids have also been shown to delay the time to recovery in such patients. The result? Patients with a simple fever and sore throat are consuming a drug with a long list of side-effects, including depression and sexual dysfunction.
To compound it all, unnecessary CT scans and blood investigations are sending patients in a frenzy, as they try to make sense out of long lab reports that in reality have nothing useful to tell them. Many private-clinic doctors, and quacks, have been known to ask for chest CT scans for patients as soon as the latter have tested positive for COVID-19.
These scans are futile because the sort of major changes that a CT scan can ‘see’ only show up seven days after symptom onset, and with clinical deterioration. Unfortunately, CT scans are quite expensive (upwards of Rs 4,000), potentially increasing the out-of-pocket expenses of already drained patients and their families, and expose a patient to radiation equivalent to 200-500 chest X-rays each time one is taken.
Recently, Dr Randeep Guleria, the director of AIIMS New Delhi, advised against the misuse of CT scans saying they can increase the risk of cancers in the future. A chest X-ray is a more pragmatic and cheaper alternative for people with mild to moderate COVID-19. They also produce reports faster, and the results are more easily understandable.
Blood investigations are important to predict the future course of illness in all COVID-19 patients. However, some of these tests can be futile, even misleading. For example, ordering a Widal test for typhoid in patients with COVID-19 has become common practice. It is a very non-specific test that yields false-positive results in a lot of COVID-19 patients. This creates unnecessary anxiety in patients and their relatives. If you have heard that someone got typhoid and COVID-19 at the same time, it’s quite likely that the typhoid test yielded a false positive.
Doctors have also been known to prescribe strong antibiotics like ciprofloxacin for false-positive typhoid, which can then potentiate the problem of antibiotic resistance. Widal tests should only be used among patients with high clinical suspicion and should be supplemented with blood culture.
Further, a pricey test called serum IL-6 is often prescribed along with other inflammatory markers. Blood levels of various inflammatory markers like LDH, ferritin, CRP and IL-6 are important determinants of clinical course and aggressiveness of therapy. Higher levels in the blood of these markers point to a dysregulated and hyperactive immune system, which can exacerbate the lung injury in COVID-19. However, the price of one IL-6 test is Rs 3,000-4,000.
Among the commonly ordered tests for inflammatory markers, IL-6 can be easily dropped as other cheaper tests paint a better clinical picture. The IL-6 test should preferably be used among patients with a profound risk of developing a cytokine storm and deterioration. It is very easy for a doctor to scribble three letters with a dash on a sheet, but it can be woefully costly for someone who is not well-off.
Contrary to common perception, doctors usually do not over-prescribe because they are greedy for kickbacks from laboratories or drug companies. With strict government guidelines and patient empowerment, referral commissions have become less common, even if they persist in some parts as a plague on the medical system.
In addition, since a lot of COVID-19 consultations happen online, it is difficult to imagine how a doctor in another city could earn a ‘cut’ if you got a CT scan from a lab in your neighbourhood.
The acts of over-prescription are often governed by action bias. With stress and fear associated with COVID-19, people tend to prefer action over inaction – even if the action is futile. For example, relatives and doctors often desperately look for convalescent plasma when a loved one is in the terminal stages of COVID-19, even though this therapy has not been found useful in such cases. As a last ditch effort, patients and doctors tend to act rather than passively see the patient pass in front of them.
The fear of death forces recently diagnosed COVID-19 patients to expect long prescriptions and comprehensive advice, even if this information just doesn’t – or shouldn’t – exist. Patients often ask physicians if they are to restrict their diet in any way, and they feel better if the physician points something out and says it should be avoided. The requirement for specific dietary restrictions seldom exists.
As psychologists can explain, a COVID-19 diagnosis is perceived as sad news, and in response people often undergo the five stages of grief (according to the Kubler-Ross model):
1. Denial – ‘But I followed all precautions!’
2. Anger – ‘This is the government’s mistake!’
3. Bargaining – ‘I will not eat my favorite food. I will sincerely get the tests and medicine. Just save me, God.’
4. Depression – ‘Am I dying? What will happen?’
5. Acceptance – ‘This shall too pass.’
The mental satisfaction that comes with following a long prescription and heeding futile advice may be related to the bargaining stage of grief.
We need explicit, comprehensive and continuously updated government guidelines for COVID-19 prescriptions – to prevent unnecessary expenses and side-effects. The health ministry should also create a policy to ensure COVID-19 treatment in the country is uniform, and uniformly enforced.
Finally, the physician’s personal judgment may be required at times, instead of every patient being forced to agnostically consider the evidence. As the researchers behind one 2018 paper wrote, “Would you jump from a plane without a parachute just because there are no randomised controlled trials to prove that it saves lives?”
But for every other case, there needs to be some codification to stave off the ‘chaos medicine’.
Amulya Gupta is pursuing an MBBS at the All India Institute of Medical Sciences, New Delhi. He is part of the India COVID Apex Research Team (I-CART), and recently started a patient education website, maladyscience.com. He tweets at @dramulyagupta.
A supposedly Ayurvedic concoction of spices concentrated in hot water↩